PHARMACOLOGICAL TREATMENT

• Patients who are younger than 55 years can be managed with an initial empirical strategy that is based on the prevalence of Helicobacter pylori infection in the community [20-23].
• In communities where the prevalence of H pylori infection is 10% or greater, an initial strategy of testing and treating for H pylori is recommended. Patients who fail this strategy are given proton-pump inhibitors (PPIs), with endoscopy reserved for those who fail to respond [20-23].
• In populations where the prevalence of H pylori infection is less than 10%, the initial strategy may be empirical PPI therapy, with endoscopy reserved for those who fail to respond [20-23].
• Offer empirical full-dose PPI therapy for 1 month to patients with dyspepsia [18]
• PPIs are more effective than antacids at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia. The average rate of response taking antacid was 37% and PPI therapy increased this to 55%: a number needed to treat for one additional responder of six [18]
• PPIs are more effective than H2RAs at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia. The average response rate in H2RA groups was 36% and PPI increased this to 58%: a number needed to treat for one additional responder of five.
• Patients with dyspepsia should not receive therapy indefinitely [1]
• Early endoscopy has not been demonstrated to produce better patient outcomes than empirical treatment [18].
• If treatment with PPI is not effective in 4 weeks recommend endoscopy [7]
• If endoscopy is normal recommend H Pylori testing. If patient already taken the eradication therapy recommend testing again after 2 weeks off PPI [7]
• If H Pylori is negative reassess the diagnosis [7]
• If still the diagnosis is dyspepsia consider antidepressants, hypno or behavior therapy [7]
• Test and endoscopy has not been demonstrated to produce better patient outcomes than empirical treatment.
• Management of endoscopically determined non-ulcer dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring [18].
• If patient is greater than 55 years of age and has new onset dyspepsia, recommend endoscopy first and then treat accordingly.

Treatment of Ulcer related Dyspepsia
• Testing and treatment of H. pylori is the cornerstone of the management of peptic ulcer disease.
• Maintenance PPI treatment is not indicated for those experiencing symptom resolutions after treatment. Patients with complicated peptic ulcer disease may be considered for maintenance treatment using PPI at one-half the therapeutic dose after successful treatment.
• Documenting H. pylori eradication should be limited to those with a history of complicated peptic ulcer disease.
• Patients who continue nonsteroidal anti-inflammatory drugs (NSAIDs) during treatment for peptic ulcers should have the duration of PPI treatment extended to twelve weeks total.
• Symptoms continuing for a month or more into treatment should prompt endoscopy regardless of initial treatment. Further evaluation may be necessary.

H. pylori Infection
• In most patients with dyspepsia, testing for H. pylori infection is the first step.
• H. pylori testing without endoscopy, followed by eradication treatment for patients with positive results, is a cost-effective approach for initial long-term management of dyspepsia
• Post-treatment testing is not generally recommended. This testing may however be indicated in selected patients with complicated ulcer disease, low-grade gastric mucosa associated lymphoid tissue (MALT) lymphoma and following resection of early gastric cancer.
• If testing is performed for eradication, it should be delayed at least 4 weeks after the completion of therapy and/or the use of proton pump inhibitors.
• Many regimens are effective in treating H. pylori. However, all regimens require more than one drug.